Lacerations Overview

by: Todd H. Chaffin, M.D.

As a physician, I am often asked what wounds need to sewn
or surgically repaired. The reality is that few wounds "need
to be repaired" because a body's healing potential is
tremendous. Most wounds if not contaminated or harboring a
foreign body, as long as they don't get infected, will eventually
heal given enough time and local treatment. The problem is,
certain wounds are best treated with some type of surgical
closure in order to afford the best healing potential. What
this means is that the sooner a wound is repaired, the better
is the cosmetic result, i.e. less scaring. An example would
be a 2" superficial cut on the thigh would heal satisfactorily,
as would a ½" laceration on your face. The laceration
on your face, however, being of cosmetic importance, will
most often best be treated with some type of prompt surgical
closure. The faster a wound heals, the less scarring and less
chance for infection

What should I do if medical help is not readily available?
The most important wound care principle is wound irrigation.
"The solution to pollution is dilution" is a commonly
sited medical axiom. Whether a wound is ever surgically repaired
or not, the most important thing is to irrigate the wound
with copious amounts of sterile saline and if unavailable,
tap water. This dilutes any bacterial contamination and removes
any particulate matter that can increase a wound's potential
for infection. The next most important principle is to remove
any foreign material or foreign bodies as best as possible.
Following this, approximating the wound edges (with tape or
bandage) facilitates re-epithelialization (the body's natural
tendency to contract and seal over a wound). The best cosmetic
outcome and least amount of scarring will occur. This process
takes place best in a moist (not wet) environment. If you
have antibiotic ointment, it can be provided in a thin film
over the wound that will allow the wound to retain moisture.
If this is unavailable, a sterile saline, moistened gauze
applied over the wound is acceptable. Sterile gauze and wrap
are then applied. Leaving the wound "open to dry"
allows for scab formation and crusting to develop and may
make for a worse cosmetic appearance. The wound should be
covered in this fashion until adequate healing has occurred,
which may be anywhere from 1-2 weeks, depending on the location.
Wounds involving the head, face and upper extremity tend to
heal more rapidly then wounds further from the heart. The
better the blood flow, the quicker wounds tend to heal. Wounds
on the feet and legs tend to heal the slowest for this reason.

When should I seek medical attention for a wound? Generally,
if the wound is more than ½" long, is gaping open,
is dirty, retains a possible foreign body, or is cosmetically
important to repair surgically, or if there is a potentially
deep penetration (such as a knife stab wound). Also, or if
there is any perceived function loss such as motion, circulation
or sensation, then these should be evaluated by medical personnel
as promptly as possible.

What do I do if I can't get to a medical facility? As outlined
above, the wound should be irrigated and a dressing applied.
In the past it was thought that there was a "golden period"
ranging up to 12-24 hours after which a wound should not be
surgically closed. This has been refuted by several large
studies. Most wounds, even days old, can be surgically repaired
as long as they are not infected. It is always best to have
wounds evaluated by trained medical personnel if there is
any doubt in one's mind as to whether the wound can be managed
by local first aid measures, or requires greater medical expertise.
The above recommendations are made only to assist those who
do not have readily accessible medical care.

Treating Lacerations

by: Dan Williams, Psy. D., PA-C

Outdoor treatmentMany individuals who hunt, fish, camp
and hike eventually sustain a laceration. This article will
address specifically what to do in the outdoors scenario.

Irrigate, irrigate, irrigate. Most individuals
will not have a syringe to push fluid through the wound.
A plastic bag will work wonders. Fill your plastic bag with
water and punch a tiny hole on the end. Squeeze the end
like using a cake decorating bag. You now have a pressure
irrigation system.

If the wound is gaping and still bleeding,
you may want to close the wound, especially if transportation
to a medical facility is delayed greater than 72 hours.
First, to stop the bleeding, you can soak gauze with Afrin®
or nasal spray containing Neo-synephrine. Apply this to
the wound. This will act as a vasoconstrictor and slow the
bleeding enough so you can bandage and take care of the
wound. Also gauze soaked in Benadryl® works wonders
as nice topical anesthetic.

Most individuals will not have Benzoin and
steri-strips with them. In the absence of these medical supplies,
tape can be used to temporarily close the wound.

Cut the hair around the wound so the tape
will stick.

Do not shave the area as this will induce
more bacteria into the wound and increase chances of infection.

Topical antibiotics? Survive Outdoors recommends
Bacitracin as opposed to Neosporin. Approximately 10-15%
of the general population is allergic to the Neomycin in
Neosporin. Many clinics to not even stock Neosporin due
to this factor. The absence of a topical antibiotic is fine.
Most people in Western society fall prey to wanting to do
more than less. In this scenario, less is best.

Bandage the wound. Nonstick Telfa is excellent
to apply first with a pressure dressing. Wrap the wound
as you would a sprained ankle. Observe for wrapping too
tightly, as circulation distal to the wound may be impaired.
If the skin away from the wound is close or pale, loosen
the bandage.

Splinting is helpful. It decreases movement.
When you decrease movement, you decrease bleeding.

Keep the wound dry for 24-hours. Do not
get it wet. After the first 24-hours, cover the wound during
the day, leave open to air at night. All wounds need oxygen
to heal as stated in our eye injury section. Covering of
the wound and then leaving it open to air is a fine balance.
When the wound is covered too much, the skin around the
wound becomes macerated or white in appearance. This is
a sign that you have left it covered for too long. If the
skin is dry and scaling, you have left it open to the air
too long. Clean daily with basic soap and water and dry
well.

Observe for signs of infection: Warmth
at the wound site, pus draining, redness moving up the extremity
(lymphangitis) are all signs of infection. Fever, swollen,
tender lymph nodes, and lymphadenitis are advanced signs
of infection. If these late signs and symptoms occur, transportation
needs to occur quickly.